NURS 6912 Week 11 reflection example

Mentioned Often, Managed Never: A Structured Reflection on Why I Left Fatigue to the End of Every Symptom Plan

Student Name

College of Nursing, Walden University

NURS 6912: Symptom Management for the Hospice and Palliative Care Clinician

Instructor Name

Month Day, Year

Mentioned Often, Managed Never: A Structured Reflection on Why I Left Fatigue to the End of Every Symptom Plan

Description

Of all the symptoms this course covered, fatigue is the one I have handled worst, and I did not notice until I reread my own work. I had thought of myself as thorough, a nurse who asks about everything, and the discovery that one symptom had slipped through every plan I wrote was not what I expected to find when I began this assignment. I went back through the plans I wrote this term and searched each for the word. In my pain assessment for the man with spinal metastases, fatigue appeared once, in a list: "also reports fatigue." In my gastrointestinal plan, it appeared in the assessment and nowhere in the management. In my delirium case, I wrote that the patient's daytime drowsiness was "likely due to disease progression" and moved on. Across the term, fatigue appeared in nearly every case and received a management plan in none. This reflection follows the model of structured reflection (Johns, 1995), which guides the writer through a sequence of cue questions about the experience, the influences on it and the alternatives, to ask why.

Reflection: What Was I Trying to Achieve?

In each plan, I was trying to solve the problem that seemed most urgent and most solvable. Pain had clear measures, drug classes and a place in every guideline. Constipation had a causal chain I could draw. Delirium had a checklist of reversible causes. Fatigue seemed different: always present, rarely urgent and without an obvious fix. I think I placed it last because I did not believe I could do anything about it, and a plan section with nothing in it felt like a failure. Leaving it out felt safer than writing "fatigue: supportive care" and admitting I had nothing to offer.

Influencing Factors

Three influences stand out. The first is a belief that fatigue is simply the price of serious illness, something patients must accept. I absorbed that belief early in my nursing career, when fatigue in patients receiving chemotherapy was described to me as expected and temporary. The second is a habit of treating what can be measured quickly. I had a number for pain at every visit, but I had never used a fatigue measure, so fatigue was always described in words, and words are easy to skip. The third is the case prompts themselves. Most of this term's scenarios named another symptom as the focus, and fatigue appeared as background. I followed the prompts' emphasis without questioning it.

There was also something personal. When patients describe exhaustion, I recognize my own tiredness after long shifts, and I think I minimized theirs partly because I minimize mine. That is uncomfortable to write, but it may explain why the belief that nothing can be done felt so natural.

Alternatives: What Could I Have Done?

The readings showed me that there was more to do than I believed. First, fatigue can be measured. The Brief Fatigue Inventory asks patients to rate fatigue now, at its usual level and at its worst, and how much it interferes with activity, mood, walking, work, relationships and enjoyment of life, and it was developed to be quick enough for routine use (Mendoza et al., 1999). Using it would have given fatigue a number on every visit, just as pain had.

Second, fatigue has contributors that can be looked for and sometimes treated: anemia, depression, poor sleep, pain, medication effects, low thyroid function, dehydration and deconditioning. My delirium patient's drowsiness, for instance, might have prompted a review of her opioid and her calcium before I attributed it to progression.

Third, fatigue can be treated. Pooling trials of drugs, talking therapies and physical activity for cancer-related fatigue, Mustian et al. (2017) found the two nondrug approaches came out ahead, both while people were in treatment and afterward, and the medicines tested did comparatively little. The findings come mainly from people receiving or recovering from cancer treatment, so they apply only partly to patients near the end of life, but they undermine my belief that nothing can be done. Energy conservation, pacing, brief activity matched to ability and better sleep are all within a nurse's reach.

Learning

I have learned that the symptoms I treat well are the ones I measure, and that my belief that a symptom is untreatable can become a reason not to look. If I had applied to fatigue the same approach I applied to pain, measure it, look for causes, treat what can be treated and reassess, my plans would have had something to offer patients for whom fatigue was, as several of them said in the case prompts, the worst part of their day.

I also learned that the case prompts shaped my attention more than I realized. A prompt that names pain as the focus does not mean fatigue is unimportant; it means the prompt's author chose a focus. In practice, no one will write a prompt for me, and the patient's ranking of symptoms should set my focus, as it did in my kidney disease plan, the one place this term where I treated tiredness as a symptom in its own right. That plan was also the one where I asked the patient to rank his symptoms first, which suggests the fix is partly procedural: when patients set the order, the symptoms I overlook have a way back in.

Action Plan

I will make three changes. For the next three months, I will include a fatigue rating in every symptom assessment I complete, using the Brief Fatigue Inventory's usual-fatigue item as a minimum. When a patient rates fatigue at 4 or higher, I will review the common contributors before concluding that it reflects the disease alone. And every symptom plan I write will include a fatigue section, even if it contains only pacing, sleep and a reassessment date, so that fatigue is never again left out because I thought there was nothing to say. I will review my own plans at the end of each month and count how many carried a fatigue section, so I can see whether the habit is changing rather than assuming it has.

References

Johns, C. (1995). Framing learning through reflection within Carper's fundamental ways of knowing in nursing. Journal of Advanced Nursing, 22(2), 226-234. https://doi.org/10.1046/j.1365-2648.1995.22020226.x

Mendoza, T. R., Wang, X. S., Cleeland, C. S., Morrissey, M., Johnson, B. A., Wendt, J. K., & Huber, S. L. (1999). The rapid assessment of fatigue severity in cancer patients: Use of the Brief Fatigue Inventory. Cancer, 85(5), 1186-1196. https://doi.org/10.1002/(SICI)1097-0142(19990301)85:5<1186::AID-CNCR24>3.0.CO;2-N

Mustian, K. M., Alfano, C. M., Heckler, C., Kleckner, A. S., Kleckner, I. R., Leach, C. R., Mohr, D., Palesh, O. G., Peppone, L. J., Piper, B. F., Scarpato, J., Smith, T., Sprod, L. K., & Miller, S. M. (2017). Comparison of pharmaceutical, psychological, and exercise treatments for cancer-related fatigue: A meta-analysis. JAMA Oncology, 3(7), 961-968. https://doi.org/10.1001/jamaoncol.2016.6914